The "Five Whys" technique originates from the Toyota Production System and was developed by Sakichi Toyoda to resolve product design issues. It has since been adapted as a common tool to identify the root cause of a problem by repeatedly asking the question "Why?"—typically five times—until the underlying issue is revealed. Each answer forms the basis of the next question. This approach is meant to go deep into the patterns that exist that created the conditions under which the event occurred. The goal of this approach is to find the fundamental cause, rather than simply addressing immediate symptoms, thus enabling more effective and long-lasting solutions.
Figure One gives a simple example of a Five Whys Analysis. In this example, the approach is applied to a cut to my hand when cutting a potato into wedges while making dinner.
A sixth why would yield something like I have no schedule or program for properly maintaining my household tools.
Once a Five Whys analysis is conducted, users usually perform it multiple times, exploring each apparent cause as a separate path. After doing such an analysis on this simple event, the other paths that may have been identified would be:
My hand was not protected from being cut (e.g., cut resistant glove or guarding).
I failed to take note of the potato positioning, and potential "tater" teeter, because I was paying attention to my kids.
I don't have enough time in the evening after work and carpooling, to prepare dinner with care.
Even with this simple scenario, other than sharpening knives before each use, notice how taking care of all of these "root causes" would need corrective actions involving significant investment, or lifestyle changes. Actions like purchasing prepared vegetables (but could you totally eliminate knife or sharp edge use?), changing recipes to use whole vegetables, eating out, guarded gadgetry, physically sequestering children from prep area, hiring a nanny, changing jobs so I can be home earlier, etc. Then there is the introduction of other variables with potentially worse consequences (e.g., contamination from cut resistant glove reuse gets my three-year old sick, or slicing finger deeper with sharpened knives, etc.).
In addition to significant lifestyle changes and investment, is my commitment (as a leader) to those changes in bringing about the right change, and preventing future occurrence. For example, there is no direct tie to the fundamental issue of not enough time after work to take proper care when cooking. On several, in fact every other night after work previously, getting home late did not result in me cutting my finger. This is the problem in industry as well, where analyses reveal such aspects as "there is too much emphasis on production" or "we don't have standardized work areas". So what is going on here?
Well, as it turns out, The Five Whys structures thinking to confirm our bias by looking for known, related, sequential, negative events or conditions, and then forcing them to fit into an absolute scenario scheme. as described in Figure Two.
In truth, it was "at best" the alignment of events and conditions on that particular day, and the likelihood of it occurring in the same manner again is minimal—especially now that since I am aware of the potential outcome, I will change my behavior. It might even stem from incorrectly assumed connections, such as believing my cut was due to the children distracting me and being hurried to prepare dinner, when in reality, it was my own lack of focus and my mind distracting me from what I was doing. Figure Three demonstrates the messiness of the events that are furthest away from the event in a Five Why Analysis.
But there is a more serious aspect to the methodology of Five Whys; it lulls leaders into a false sense of security that systemic issues are getting prioritized and addressed, and they don't perform regular holistic reviews of system design and subsequent risk. But make no mistake, when our practice to resolving workplace injuries involves identifying systemic issues and their connection to real or potential injuries, this becomes our system for identification of systemic issues (i.e., an injury triggers our systemic issue review). By design, this is an ineffective approach, as an injury has already occurred!
As leaders we are compelled by a prioritization of workplace safety and wellness, to proactively review our systems and workplace for systemic or fundamental issues for resolution through risk management that will yield the appropriate prioritization. In addition, by focusing on the specific injury (e.g., a cut finger and not a potential for a burned hand in the kitchen), we ignore semiotic cues (signals to and from our environment) that facilitate risk self-management, cognition, and awareness of system participants.
Just imagine if a business was made up of people at all levels of the organization that were proactive, thought deeply about what they were doing and about to do, were fast and right in their thinking, and took the time to understand the environment they were entering (even if they had done it 1000 times before) garnering critical information from their environment, and projecting risk-managing communications (like completing a safety checklist, or hot permit, wearing a yellow safety vest, setting up traffic lanes, declaring a construction zone, etc.). Thinking is not a given and it is often absent or incorrect when incidents happen or conditions are not safe. Thinking is the catalyst to events of "now" and in the future. Yet rarely is understanding bad thinking part of an incident investigation or collaboration practices of leadership.
Therefore, I propose an approach that combines a debriefing of the occurrence for immediate cause correction and procedural change, while there is proactive analysis of the system by leadership with a proper sense of frequency and urgency.
Using the home injury as an example, first, identify the relationship between the system of making dinner that includes "cutting my finger", and a system of "not cutting my finger", then identify the parts of that relationship and how those parts are connected. See Figure Four:
This relationship, which might be called "Awareness and Preparation" would start with applying semiotics and better thinking and buttressing my cognition. This would lead to collecting ingredients and equipment and identifying risks, which would then lead to knife sharpening, washing vegetables, wrapping the handle of my oven skillet with foil to create a signal to my mind it could be hot, etc. All of these actions become procedural changes-and in the workplace would be documented as such. Of course, in the workplace there should be specific actions to engineer out potential injury (e.g., eliminating knife use) and if not, safeguards (e.g., PPE, guarding, etc.) and standardization.
If this approach is applied in the workplace, concrete improvements to local systems get implemented while the onus of proactive systemic issue identification resides where it belongs, with leadership. Risk management and system design become critical actions of leader activity that have urgency. Understand what happens here: the system design is reviewed as a whole and priorities set based upon the view of the whole, rather than from loose connections from incidents and injuries. This activity in and of itself has the distinction of being critical to leaders, and therefore not delayed or deprioritized. With this ownership and prioritization approach, leaders gain a far better understanding of the system, and its risks.
Lori G. Fisher
PLS Management Consulting, a strategic partner of Cabrera Lab
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